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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347000985
Report Date: 01/28/2025
Date Signed: 01/28/2025 04:43:23 PM

Document Has Been Signed on 01/28/2025 04:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GOLDEN POND RETIREMENT COMMUNITYFACILITY NUMBER:
347000985
ADMINISTRATOR/
DIRECTOR:		RYAN NAKAOFACILITY TYPE:
740
ADDRESS:3415 MAYHEW ROADTELEPHONE:
(916) 369-8967
CITY:SACRAMENTOSTATE: CAZIP CODE:
95827
CAPACITY: 175TOTAL ENROLLED CHILDREN: 0CENSUS: 87DATE:
01/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Ryan NakaoTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Unannounced Annual Inspection visit was made by Licensing Program Analyst (LPA) Kimberly Viarella to this facility on 1/28/25. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator/ Executive Director (ED). LPA met with ED, Ryan Nakao, (certificate # 6066510740 expires on 03/01/25) and a brief interview followed.

The tour began in the kitchen. LPA inspected pantry area and pulled sample of a dozen dry goods to ensure that all were dated and stored properly. LPA then inspected the walk-in refrigerator and freezer. All food items were dated and packaged properly at the time of this inspection. The hood over the primary stove was last inspected on 11/07/24 by Niagara Hood Cleaning and it was in compliance at the time of this inspection. LPA also observed that fire extinguishers were last inspected on 8/30/2024 by Foothill Fire Ins. and were also in compliance. LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days.



LPA, escorted by the Marketing Director, entered a resident’s room in memory care, as the door had been left open. LPA pulled the emergency cord in the bathroom to test response time. After 20 minutes, the LPA and the Marketing Director left the room to alert the Memory Care Director to the fact that they had gotten no response.

LPA located the Memory Care Director (MCD) along with 2 care staff assisting 8 of the 12 residents in memory care with lunch. LPA informed the MCD and the ED about the lack of response to the alert activated.
LPA inspected 2 resident rooms memory care. Each had the required furniture, furnishings, and lighting to be in compliance. Bathrooms had grab papers, towels, and non-skid surfaces in the showers. Hand soap was locked and inaccessible to residents in care. LPA provided technical assistance regarding non-toxic soap being available for residents to use after using the restroom. Locked cabinets were present in each of the memory care bathrooms to store personal care items that required supervision for resident use.
Stephen RichardsonTELEPHONE: (916) 263-4746
Kimberly ViarellaTELEPHONE: (916) 809-5764
DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GOLDEN POND RETIREMENT COMMUNITY
FACILITY NUMBER: 347000985
VISIT DATE: 01/28/2025
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LPA began a file resident file review, but due to time constraints, Community Care Licensing will return at a later date to complete this annual inspection.

According to the California Code of Regulations, Title 22, no deficiencies were cited during today's visit. A copy of this report was provided and an exit interview conducted.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC809 (FAS) - (06/04)
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